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Application for Death Certificate

  1. Name on Record:

  2. Date of Death:

  3. Place of Death:

  4. Father's Name:

  5. Mother's Maiden Name:

  6. Applicant's Name:

  7. Applicant's Physical Address:

  8. Mailing Address:

  9. Payment must accompany the Death Certificate Application.
    If you are mailing in the application please include a check or money order,
    if you are hand delivering the application we accept cash, check or money order.

  10. WARNING: The penalty for knowingly making a false statement on this form can result in 2-10 years in prison and/or a fine up to $10,000 per the Health and Safety Code, Chapter 678, Section 195.003

  11. Birth Records are confidential for 75 years; therefore, issuance is restricted. Administrative rules require that on restricted records, all identifying information listed above be provided in order to issue the record.

  12. Leave This Blank: